Abstract

We describe a very unusual contact charcoal burn associated with acute central cord syndrome. The patient is a known case of cervical degenerative disc disease who accidentally slipped and fell down in hot charcoal with sudden neck hyperextension. This lead to acute central cord syndrome, quadriplegia, loss of sensation, and bilateral lower limb 4th degree burn requiring amputation. The case is reported to increase the awareness of burn surgeons to burns associated with central cord syndrome.

Keywords

Burn, Charcoal, Central cord syndrome

Introduction

Contact charcoal burn is a well known entity and has been
reported to occur by three mechanisms. Recreational activities
(especially on the beach) frequently have “fire
pits” with hot charcoal. Both children and intoxicated
adults can fall into these “fire pits” sustaining deep burns
involving different parts of the body [1,2]. Camp-fires
while camping in the desert is also a common practice by
families on weekends in Saudi Arabia. Crawling infants
into the hot charcoal sustain deep burns of the palms [3].
In the Far-East, "burning charcoal" in an enclosed space is
a common method of committing suicide. When the suicide
is unsuccessful, the unconscious patient may fall on
the hot charcoal resulting in a localized deep burn that
frequently requires primary free flap coverage [4,5].
In this paper, we describe a very unusual charcoal burn
associated with acute central cord syndrome.

Case report

Our patient is a 72-year old male who is known case of
cervical degenerative disc disease. He was camping alone
in the desert and put up a charcoal fire inside his tent. He
accidentally slipped and fell down with sudden neck hyperextension.
The left leg was in contact with the charcoal
and the right leg was adjacent to the charcoal. Neck
hyperextension led to acute central cord syndrome with
quadriplegia and loss of sensation of the limbs. He was
fully awake but was unable to move his insensate legs
away. His friends came by five hours later, and immediately took him to the hospital. On presentation to
our emergency department, the left leg was burnt to ashes
(Fig 1a). The right leg had fourth degree burns with a
devascularized foot. Right leg fasciotomy was done in
the emergency room and showed necrotic muscles (Fig 1b). The posterior aspect of both thighs and the perineum
also had third degree burns from contact to the hot sand.
Neurological examination showed a fully conscious man
with quadriplegia and complete loss of sensation. There
was also urinary retention. An MRI showed diffuse cervical
degenerative disease with a spondylotic disc osteophyte
complex and hyperintense signal of the spinal cord.
There was no significant spinal canal stenosis and there
were no fractures. The clinical and radiological findings
were consistent with acute central cord syndrome and our
neurosurgeon elected for conservative management. The
patient underwent left above-knee amputation and right
below-knee amputation. The posterior aspect of the
thighs and perineum required tangentional excision and
skin grafting, and there was full skin graft take. Starting
on the second day after injury, the neurological status of
the patient gradually improved. The patient regained
urine and fecal continence. Sensory recovery of the upper
limbs was complete with normal 2-point discrimination of
all digits. The motor recovery, however, was incomplete.
The upper limb motor power was graded as 4 out of 5
(active motion against resistance) by the Medical Research
Council (MRC) scale for muscle strength. The
motor power of both hips and the right knee were complete
and were graded as 5 out of 5 by the MRC scale.
The patient is now 6 months after injury and is able to
live independently with a wheelchair.

Figure 1a: Appearance of the left lower limb burn.

Figure 1b: Appearance of the right lower limb burn.

Discussion

Our literature review did not reveal any burn cases directly
related to acute central cord compression syndrome. The
syndrome was first described by Schneider et al. [6] in
1954. It is commonly seen in the elderly with degenerative
cervical disc disease. A sudden hyperextension of the neck
in these patients results in acute central cord compression
by the spondylotic disc osteophyte complex [7]. The central
cord syndrome presents as a spectrum, from weakness limited
to the upper limbs with sensory preservation, to quadriplegia
and complete loss of sensation. Most patients recover
well with conservative management and surgery is
indicated only in patients with significant spinal canal
stenosis or spinal instability. Our patient had severe acute
symptoms and recovered well although sensory recovery
was better than motor recovery, and motor recovery of
lower limbs was better than motor recovery of the upper
limbs. The reason for the relative sensory preservation and
the relative motor preservation of the lower limbs is thought
to be related to the development of a "central" intraparenchymal
spinal cord hematoma leading to injury to the decussating
corticospinal tracts [7].

“Fourth degree" burn is a term that is occasionally used to
describe lower limb burns with exposed tendon and bone
[8]. The burn degree of the left leg in our patient was even
deeper with the injured area turning into ashes at the scene
(Fig 1a). The prolonged contact to charcoal explains the
severity of the burn injury in the left leg. In contrast, the
prolonged contact to the hot sand explains the burns in other
areas.

In conclusion, we report a very unusual case of charcoal
contact burn associated with central spinal cord syndrome to
increase the awareness of burn surgeons to this mechanism
of injury.

Disclosure

There is no conflict of interest

Funding

The work was funded by the College of Medicine Research
Center, Deanship of Scientific Research, King Saud University,
Riyadh, Saudi Arabia.